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Admin
HEALTH
CONSULTANTS
To serve you with the best of science and nature
NUTRITIONAL HEALTH APPRAISAL QUESTIONNAIRE
NO ANSWER IF THE SYMPTOM DOES NOT APPLY:
1
FOR A MILD SYMPTOM
2
FOR A MODERATE SYMPTOM
3
FOR A SEVERE SYMPTOM
ONLY WOMEN ANSWER QUESTIONS MARKED "F"
ONLY MEN ANSWER QUESTIONS MARKED "M"
Name:
*
Sex (M/F):
*
Phone:
Email:
*
Date:
*
1:
acne, blackheads or warts
2:
dry, rough skin
3:
yes dont adjust in a dark room
4:
difficulty seeing at night
5:
goosebumps on backs of arms or legs
6:
frequent colds; respiratory infections
7:
poor appetite
Total(1):
8:
frequent fatigue
9:
irritability
10:
depression
11:
craying for sweets
12:
can't concentrate
13:
fits of temper
14:
hurt all over (general)
15:
heart palpitation
16:
greying hair
Total(2):
17:
bleeding gums
18:
bruise easily
19:
varicouse veins or broken capillaries
20:
frequent colds or flu
21:
smoke over half a pack a day
22:
slow healing of cuts or scrapes
23:
hangnails, cuticles tear easily
24:
excessive hair loss
25:
nose bleeds
Total(3):
[Go to Step 2]
SubTotal:
Header
26:
poor circulation
27:
lack of stamina
28:
dark circles under eyes
29:
recent history of anemia
30:
F:heavy menstrual flow
31:
thin, fragile, brittle nails
32:
pale skin, palms very pale
Total(5):
33:
F: menstrual cramps
34:
muscle twitches and tics
35:
fingernails won't grow
36:
foot or leg cramps
37:
insomnia
38:
muscle tension
39:
joints pop or crack (not due to surgery)
40:
frequent backache
41:
aching joints or muscles
42:
crave chocolate
Total(6):
43:
bad breath
44:
white-coated tongue
45:
white spots on fingernails
46:
thinning hair
47:
diminished sense of smell or taste
48:
slow healing of wounds
49:
F: taking estrogen (the pill, or premarin)
50:
dandruff
Total(7):
[Go to Step 3]
SubTotal:
Header
51:
nausea, headache, migraine
52:
history of hepatitis, jaundice, malaria
53:
recent history of constipation
54:
gall bladder or stones removed
55:
yellow-colored bowel movements
56:
undigested food in stools
57:
coated tongue
58:
bad breath, bad taste in mouth
59:
occasional body odor, including feet
60:
frequent tension in shoulders and neck
61:
abdominal pain after meal
Total(9):
62:
recent history of colitis, diverticulitis
63:
painful, hard bowel movements
64:
alternating constipation and diarrhea
65:
desire to eat often, especially starches
66:
recent history of hemorrhoids
67:
recent history of rectal fissure
68:
F: constipation during menstruation
69:
rarely have daily bowel movements
70:
thin, pencil-like bowel movements
Total(10):
71:
heavy, tired feeling after eating
72:
gas after eating
73:
stomach bloated after eating
74:
belching, burping after meals
75:
drowsy after eating
76:
hair won't grow
77:
hair breaks easily
78:
chronic fluid retention
79:
very flabby tissues
80:
fingernail break and split
Total(11):
[Go to Step 4]
SubTotal:
Header
81:
taking pills causes stomach discomfort
82:
recent history of ulcers
83:
stomach pains 5-6 hours after eating
84:
stomach upset by tension
Total(13):
85:
F: severe pre-menstrual bloating
86:
puffy eyes
87:
ankles swell frequently
88:
infrequent urination
89:
legs often feel heavy
90:
difficult or painful urination
91:
recent history of kidney or bladder infection
92:
urge to urinate 2 or more times during night
Total(14):
93:
eyes sensitive to bright lights
94:
occasional cold sweats
95:
painful lump in throat when emotionally disturbed
96:
heart pounds when startled
97:
blood pressure fluctuates, sometimes too low
98:
perfectionist: set high standards
99:
overly concerned about things left undone
100:
allergies, skin rash, hay fever, sneezing attacks
101:
stress or emotional upsets cause exhaustion
102:
craving for salt
Total(15):
[Go to Step 5]
SubTotal:
Header
103:
F: irregular or uncomfortable periods
104:
F: menopause, hot flashes
105:
F: have had hysterectomy (enter value of 2)
106:
F: diminished sex drive
107:
F: nervous, depressed before periods
108:
F: missing periods
Total(17):
109:
M: difficult urination, starting, burning
110:
M: get up nights to urinate
111:
M: back or leg pains
112:
M: prostate trouble
113:
M: diminished sex drive
Total(18):
114:
urinate frequently
115:
intense, frequent thirst
116:
shakiness, headaches, relieved by sweets, starches
117:
irritable if meal missed or late
118:
craving for sweets alcohol or coffee
119:
emotional on empty stomach
120:
irritable before breakfast
121:
weak spells tiredness in mid-afternoon
122:
spells of faintness, dizziness, lack of concentration
123:
wake up at night feeling hungry
124:
cold sweats on hands even when warm
Total(19):
[Go to Step 6]
SubTotal:
Header
125:
very thirsty most of the time
126:
diabetes in the family
127:
occasional night sweats
128:
chronic fatigue, lowered resistance
129:
history of sores, especially on legs, heal slowly
130:
crave sweets, starches, eating doesn't help
131:
bruise easily, black & blue spots
132:
cold hands and feet, need extra cover at night
133:
short of breath after climbing stairs
134:
require extra amount of sleep
135:
low exercise tolerance & low endurance
Total(21):
136:
arms and legs often go to sleep
137:
numbness or heaviness in arms or legs
138:
hand cramps when writing
139:
tingling sensation in lips or fingers
140:
short walks cause aches and pains
141:
memory getting worse
Total(22):
142:
chest pains sometimes down left arm
143:
unexplained headache or dizziness
144:
very rapid heart beat (over 90/minute)
145:
very slow heart beat (under 50/minute)
146:
heart sometimes flip-flops
147:
shortiness of breath on exertion
148:
smoke a pack a day or more
149:
have diabetes
150:
history of heart disease in family
Total(23):
[Go to Step 7]
SubTotal:
Header
151:
history of bronchitis, asthma, pneumonia, emphysema
152:
chronic cough
153:
history of colds, lung problems
154:
chronic mucus accumulation in throat/sinus
155:
cigarette smoker
156:
work in factory, or with chemicals, fumes
Total(25):
157:
very susceptible to infections
158:
flu-like symptoms often occur
159:
swollen glands, groin, tonsillitis, throat, armpits
160:
history of cancer, MS, Parkinson's, Rheum.arthritis
161:
unusual number of cavities
162:
feel puffiness in throat
Total(26):
163:
frequent use of antibiotics
164:
F: endometriosis/ovary problems
165:
severe reaction to tobacco, perfume, odors
166:
crave sugars, bread, alcohol
167:
recurrent heartburn/digestive upsets
168:
chronic diarrhea
169:
hives, psoriasis, acne, skin rashes
170:
rectal itching
171:
bladder infections
172:
often feel tired
173:
gas, abdominal bloating
174:
abnormal muscle aches from exercise
175:
unexpected weight gain
Total(27):
176:
fluid retention
177:
nausea or dizziness
178:
anemia
179:
weakness in general
180:
low resistance to infection
181:
low hormone levels
182:
premature aging
183:
high stress lifestyle
184:
slow recovery of wounds/illness
Total:
[Go to Step 8]
THE FOLLOWING ARE FOR FEMALES ONLY!
DO ANY OF THE FOLLOWING OCCUR 14 DAYS BEFORE YOUR PERIOD?
(1 - MILD, 2 - MODERATE, 3 - SEVERE)
Header
185:
F: nervous tension
186:
F: headaches
187:
F: depression
188:
F: weight gain
189:
F: fatigue
190:
F: confusion
191:
F: increased appetite
192:
F: breast tenderness
193:
F: crave sweets
194:
F: frequent crying
195:
F: swelling hands and feet
196:
F: forgetfulness
197:
F: bloating
198:
F: backache
199:
F: menstrual cramps
Total(29):
